ABSTRACT
BACKGROUND
Chronic constipation is a prevalent disorder that affects patients' quality of life and consumes resources in healthcare systems worldwide. In clinical practice, it is still ...considered a challenge as clinicians frequently are unsure as to which treatments to use and when. Over a decade ago, a Neurogastroenterology & Motility journal supplement devoted to the investigation and management of constipation was published (2009; 21 (Suppl.2)). This included seven articles, disseminating all themes covered during a preceding 2‐day meeting held in London, entitled “Current perspectives in chronic constipation: a scientific and clinical symposium.” In October 2018, the 3rd London Masterclass, entitled “Contemporary management of constipation” was held, again over 2 days. All faculty members were invited to author two new review articles, which represent a collective synthesis of talks presented and discussions held during this meeting.
PURPOSE
This article represents the first of these reviews, addressing epidemiology, diagnosis, clinical associations, pathophysiology, and investigation. Clearly, not all aspects of the condition can be covered in adequate detail; hence, there is a focus on particular “hot topics” and themes that are of contemporary interest. The second review addresses management of chronic constipation, covering behavioral, conservative, medical, and surgical therapies.
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DOBA, FZAB, GIS, IJS, IZUM, KILJ, NLZOH, NUK, OILJ, PILJ, PNG, SAZU, SBCE, SBMB, SIK, UILJ, UKNU, UL, UM, UPUK
Esophageal cancer affects more than 4,50,000 persons worldwide, and its incidence has increased in recent years. It is the eighth most common cancer across the globe. The main histologic types are ...esophageal squamous cell carcinoma (ESCC) and esophageal adenocarcinoma (EA), and their associated risk factors are well known. Achalasia, an idiopathic esophageal disorder that conditions aperistalsis and the absence of lower esophageal sphincter relaxation, stands out among them. The prevalence of ESCC in subjects with esophageal achalasia is 26 in every 1,000 cases, whereas the prevalence of EA is 4 in every 1,000. Patients with achalasia have a 50 times higher risk of presenting with ESCC than the general population, and the disease manifests 20-25 years after achalasia symptom onset. Multiple mechanisms are related to the development of ESCC in achalasia, and they include bacterial overgrowth, food stasis, genetic alterations, and chronic inflammation. Regarding the risk of EA in achalasia patients, most cases are associated with Barrett's esophagus, due to uncontrolled chronic acid reflux. Given that achalasia is a well-established factor for ESCC/EA, clinicians must be aware of said associations to enable the development of programs for the prevention and opportune detection of these cancers in patients with achalasia.
The Lyon Consensus provides conclusive criteria for and against the diagnosis of gastro-oesophageal reflux disease (GERD), and adjunctive metrics that consolidate or refute GERD diagnosis when ...primary criteria are borderline or inconclusive. An international core and working group was assembled to evaluate research since publication of the original Lyon Consensus, and to vote on statements collaboratively developed to update criteria. The Lyon Consensus 2.0 provides a modern definition of actionable GERD, where evidence from oesophageal testing supports revising, escalating or personalising GERD management for the symptomatic patient. Symptoms that have a high versus low likelihood of relationship to reflux episodes are described. Unproven versus proven GERD define diagnostic strategies and testing options. Patients with no prior GERD evidence (unproven GERD) are studied using prolonged wireless pH monitoring or catheter-based pH or pH-monitoring off antisecretory medication, while patients with conclusive GERD evidence (proven GERD) and persisting symptoms are evaluated using pH-impedance monitoring while on optimised antisecretory therapy. The major changes from the original Lyon Consensus criteria include establishment of Los Angeles grade B oesophagitis as conclusive GERD evidence, description of metrics and thresholds to be used with prolonged wireless pH monitoring, and inclusion of parameters useful in diagnosis of refractory GERD when testing is performed on antisecretory therapy in proven GERD. Criteria that have not performed well in the diagnosis of actionable GERD have been retired. Personalisation of investigation and management to each patient's unique presentation will optimise GERD diagnosis and management.
Background
Anxiety is a significant modulator of sensitivity along the GI tract. The recently described Esophageal Hypervigilance and Anxiety Score (EHAS) evaluates esophageal‐specific anxiety. The ...aims of this study were as follows: 1. translate and validate an international Spanish version of EHAS. 2. Evaluate its psychometric properties in a large Hispano‐American sample of symptomatic individuals.
Methods
A Spanish EHAS version was developed by a Delphi process and reverse translation. Patients referred for high‐resolution manometry (HRM) were recruited prospectively from seven Spanish and Latin American centers. Several scores were used: EHAS, Hospital Anxiety and Depression Scale (HADS), Eckardt score (ES), Gastroesophageal Reflux Questionnaire (GERDQ), and the Brief Esophageal Dysphagia Questionnaire (BEDQ). Standardized psychometric analyses were performed.
Key Results
A total of 443 patients were recruited. Spanish EHAS showed excellent reliability (Cronbach´s alpha = 0.94). Factor analysis confirmed the presence of two factors, corresponding to the visceral anxiety and hypervigilance subscales. Sufficient convergent validity was shown by moderate significant correlations between EHAS and other symptomatic scores. Patients with high EHAS scores had significantly more dysphagia. There was no difference in EHAS scores when compared normal vs abnormal or major manometric diagnosis.
Conclusions and Inferences
A widely usable Spanish EHAS version has been validated. We confirm its excellent psychometric properties in our patients, confirming the appropriateness of its use in different populations. Our findings support the appropriateness of evaluating esophageal anxiety across the whole manometric diagnosis spectrum.
The Spanish version of the esophageal hypervigilance and anxiety score shows strong psychometric properties: Results of a large prospective multicenter study in Spain and Latin America.
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DOBA, FZAB, GIS, IJS, IZUM, KILJ, NLZOH, NUK, OILJ, PILJ, PNG, SAZU, SBCE, SBMB, SIK, UILJ, UKNU, UL, UM, UPUK
Background
Eckardt symptom score (ESS) is the most used tool for the evaluation of esophageal symptoms. Recent data suggest that it might have suboptimal reliability and validity. The aims of this ...study were as follows: (a) Develop and validate an international Spanish ESS version. (b) Perform psychometric ESS evaluation in patients with achalasia and non‐achalasia patients.
Methods
Eckardt symptom score translation was performed by Delphi process. ESS psychometric evaluation was done in two different samples of patients referred for manometry. First sample: 430 dysphagia non‐achalasia patients. Second sample: 161 achalasia patients. Internal consistency was evaluated using Cronbach's α and Guttman coefficient (<0.5 = unacceptable. 0.5‐0.7 = fair. >0.7 = acceptable).
Key Results
Our data show that in patients without and with achalasia, ESS behaves similarly. Both show a fair reliability with Cronbach's α of 0.57 and 0.65, respectively. Based on our results, we recommend interpretation of the Spanish ESS be done with caution. The psychometric quality of the ESS could not be improved by removal of any items based on the single‐factor structure of the scale and no items meeting criteria for elimination.
Conclusions and Inferences
Eckardt symptom score Spanish translation was developed. ESS showed a fair reliability for the evaluation of patients with any causes of dysphagia. Our results highlight the need for development and psychometric validation of new dysphagia scoring tools.
The Spanish version of ESS showed reasonable reliability for the evaluation of patients with any cause of dysphagia, although its interpretation should be conservative. The development and psychometric validation of new dysphagia scoring tools is needed.
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DOBA, FZAB, GIS, IJS, IZUM, KILJ, NLZOH, NUK, OILJ, PILJ, PNG, SAZU, SBCE, SBMB, SIK, UILJ, UKNU, UL, UM, UPUK
Background
This manuscript summarizes consensus reached by the International Anorectal Physiology Working Group (IAPWG) for the performance, terminology used, and interpretation of anorectal function ...testing including anorectal manometry (focused on high‐resolution manometry), the rectal sensory test, and the balloon expulsion test. Based on these measurements, a classification system for disorders of anorectal function is proposed.
Methods
Twenty‐nine working group members (clinicians/academics in the field of gastroenterology, coloproctology, and gastrointestinal physiology) were invited to six face‐to‐face and three remote meetings to derive consensus between 2014 and 2018.
Key recommendations
The IAPWG protocol for the performance of anorectal function testing recommends a standardized sequence of maneuvers to test rectoanal reflexes, anal tone and contractility, rectoanal coordination, and rectal sensation. Major findings not seen in healthy controls defined by the classification are as follows: rectoanal areflexia, anal hypotension and hypocontractility, rectal hyposensitivity, and hypersensitivity. Minor and inconclusive findings that can be present in health and require additional information prior to diagnosis include anal hypertension and dyssynergia.
Conclusions and Inferences
This framework introduces the IAPWG protocol and the London classification for disorders of anorectal function based on objective physiological measurement. The use of a common language to describe results of diagnostic tests, standard operating procedures, and a consensus classification system is designed to bring much‐needed standardization to these techniques.
This document summarizes consensus reached by the International Anorectal Physiology Working Group (IAPWG) for the performance of anorectal function testing and introduces a consensus classification for disorders of anorectal function based on objective, physiological measurement.
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DOBA, FZAB, GIS, IJS, IZUM, KILJ, NLZOH, NUK, OILJ, PILJ, PNG, SAZU, SBCE, SBMB, SIK, UILJ, UKNU, UL, UM, UPUK
Dysbiosis, a loss of balance between resident bacterial communities and their host, is associated with multiple diseases, including inflammatory bowel diseases (nonspecific chronic ulcerative colitis ...and Crohn’s disease), and digestive functional disorders. Probiotics, prebiotics, synbiotic organisms and, more recently, pharmabiotics, have been shown to modulate the human microbiota. In this review, we provide an overview of the key concepts relating to probiotics, prebiotics, synbiotic organisms, and pharmabiotics, with a focus on available clinical evidence regarding the specific use of a unique pharmabiotic, the strain Lactobacillus acidophilus LB (Lactobacillus boucardii), for the management of gastrointestinal disorders. Since it does not contain living organisms, the administration of L. acidophilus LB is effective and safe as an adjuvant in the treatment of acute diarrhea, chronic diarrhea, and antibiotic-associated diarrhea, even in the presence of immunosuppression.
Background
Esophagogastric junction contractile integral (EGJ‐CI) and EGJ morphology are high‐resolution manometry (HRM) metrics that assess EGJ barrier function. Normative data standardized across ...world regions and HRM manufacturers are limited.
Methods
Our aim was to determine normative EGJ metrics in a large international cohort of healthy volunteers undergoing HRM (Medtronic, Laborie, and Diversatek software) acquired from 16 countries in four world regions. EGJ‐CI was calculated by the same two investigators using a distal contractile integral‐like measurement across the EGJ for three respiratory cycles and corrected for respiration (mm Hg cm), using manufacturer‐specific software tools. EGJ morphology was designated according to Chicago Classification v3.0. Median EGJ‐CI values were calculated across age, genders, HRM systems, and regions.
Results
Of 484 studies (28.0 years, 56.2% F, 60.7% Medtronic studies, 26.0% Laborie, and 13.2% Diversatek), EGJ morphology was type 1 in 97.1%. Median EGJ‐CI was similar between Medtronic (37.0 mm Hg cm, IQR 23.6‐53.7 mm Hg cm) and Diversatek (34.9 mm Hg cm, IQR 22.1‐56.1 mm Hg cm, P = 0.87), but was significantly higher using Laborie equipment (56.5 mm Hg cm, IQR 35.0‐75.3 mm Hg cm, P < 0.001). 5th percentile EGJ‐CI values ranged from 6.9 to 12.1 mm Hg cm. EGJ‐CI values were consistent across world regions, but different between manufacturers even within the same world region (P ≤ 0.001). Within Medtronic studies, EGJ‐CI and basal LESP were similar in younger and older individuals (P ≥ 0.3) but higher in women (P < 0.001).
Conclusions
EGJ morphology is predominantly type 1 in healthy adults. EGJ‐CI varies widely in health, with significant gender influence, but is consistent within each HRM system. Manufacturer‐specific normative values should be utilized for clinical HRM interpretation.
Esophagogastric junction (EGJ) morphology is predominantly type 1 in healthy adults; EGJ‐contractile integral (EGJ‐CI) varies widely in health, with significant gender influence, but is consistent within each HRM system.
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DOBA, FZAB, GIS, IJS, IZUM, KILJ, NLZOH, NUK, OILJ, PILJ, PNG, SAZU, SBCE, SBMB, SIK, UILJ, UKNU, UL, UM, UPUK
Background
The recently developed Brief Esophageal Dysphagia Questionnaire (BEDQ) evaluates esophageal obstructive symptoms. Its initial evaluation showed strong psychometric properties. The aims of ...this study were to (a) translate and validate an international Spanish version of BEDQ and (b) evaluate its psychometric properties in a large Hispano‐American sample of symptomatic individuals.
Methods
A Spanish BEDQ version was performed by Hispano‐American experts using a Delphi process and reverse translation. Patients were prospectively recruited from seven centers in Spain and Latin America among individuals referred for high‐resolution manometry (HRM). Patients completed several scores: Hospital Anxiety & Depression Scale (HADS), Eckardt score (ES), Gastroesophageal Reflux Questionnaire (GERDQ), and the BEDQ. Standardized psychometric analyses were performed.
Key Results
A total of 426 patients were recruited. Spanish BEDQ showed excellent reliability (Cronbach's alpha = 0.91). Factor analysis confirmed its unidimensional character. Moderate significant correlations between BEDQ and other symptomatic scores were found, suggesting sufficient convergent validity. Patients with abnormal or obstructive HRM findings scored significantly higher when compared to normal or non‐obstructive findings, respectively. Using a cutoff of 10, BEDQ showed a sensitivity of 65.38% and a specificity of 66.21% and an area under the curve of 0.71 for obstructive or major manometric diagnosis.
Conclusions and Inferences
A widely usable Spanish BEDQ version has been validated. We confirm its excellent psychometric properties in our patients, confirming the appropriateness of its use in different populations.
Evaluating/grading dysphagia is crucial for clinicians and researchers. We developed and validated a Spanish version of the Brief Esophageal Dysphagia Questionaire. We showed excellent reliability and validity, supporting the appropriateness of its use in Spanish speaking countries.
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DOBA, FZAB, GIS, IJS, IZUM, KILJ, NLZOH, NUK, OILJ, PILJ, PNG, SAZU, SBCE, SBMB, SIK, UILJ, UKNU, UL, UM, UPUK
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